Anesth Pain Med.  2022 Apr;17(2):221-227. 10.17085/apm.21100.

Multispecialty perspective on intradural disc herniation: diagnosis and management - A case report -

• Francio VT
• Wie CS
• Murphy MT
• Neal MT
• Lyons MK
• Gibbs WN
• Strand NH

• KMID: 2531699
• DOI: http://doi.org/10.17085/apm.21100

Abstract

Background
Intradural disc herniation (IDH) is a very rare and challenging diagnosis, with an estimated incidence of less than 1.5%. The pathogenesis of IDH remains uncertain. Definitive management remains surgical; however, some cases may initially be managed non-surgically. Case: A middle-aged male with presented with acute right-sided lumbar radiculopathy following heavy lifting. History was significant for prior lumbar disc herniation managed non-surgically. Lumbar MRI demonstrated a large disc herniation. The patient was initially treated non-surgically with epidural steroid injections. At 4-months, he re-injured and follow-up images demonstrated the herniated disc penetrating the dura and the diagnosis of intradural disc herniation. Conclusions: The present case is rare because the IDH occurred at the L3-4 level and resulted in unilateral radiculopathy without cauda-equina symptoms and occurred in the absence of prior surgery. This patient was initially treated non-surgically with satisfactory relief, however, reinjury led to progression of IDH with new neurological deficits necessitating surgery.

Keyword

Intradural disc herniation; Neurosurgery; Pain medicine

Figure

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  Fig. 1. Sagittal and axial T2 weighted images demonstrate a large disc herniation extending through the dura into the thecal sac, with lling of the thecal sac and non visualization of the nerve roots.

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  Fig. 2. Sagittal and axial T1 weighted post-contrast MRI. Marginally enhancing disc material extends through the PLL and dura. MRI: magnetic resonance imaging, PLL: posterior longitudinal ligament.

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  Fig. 3. Fluoroscopy-guided lumbar epidural steroid injection contralateral oblique view demonstrating caudal spread of contrast within the epidural space.

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  Fig. 4. Sagittal and axial T2 weighted MRI at follow-up visit. The disc herniation extends into the thecal sac, dorsally displacing the nerve roots to the posterior dural surface. The yellow arrow indicates the dorsal dura and the red arrow points to normal epidural fat. There is no visible CSF, as disc material lls the thecal sac. MRI: magnetic resonance imaging, CSF: cerebrospinal fluid.

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  Fig. 5. Intraoperative photograph of the intradural disc herniation marked by the blue arrow (A). Intraoperative photograph of exposure identifying the cauda equina rootlets marked by the blue arrow (B).

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